Atrophy of Free Fibular Grafts after Mandibular Reconstruction

Meta-analysis of the survival rate and postoperative infection rate of primary and secondary implants after vascularized fibula transplantation for reconstruction of jaw defects

OBJECTIVES

Vascularized fibula flap transplantation is the most effective and common method to repair the jaw defects. In addition, implantation is the first choice to restore dentition on the graft fibula. Implants are usually implanted at least 6 months after fibula transplantation. Primary implantation of implants during surgery can restore the dentition earlier, but whether this method can achieve the same restorative effect as secondary implantation is still uncertain. This article aims to compare the survival rate and complications between primary and secondary implantation through meta-analysis.

METHODS

This meta-analysis was conducted according to PRISMA protocol and the Cochrane Handbook of Systematic Reviews of Interventions. According to the inclusion and exclusion criteria, we selected the PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chinese BioMedical Literature Database (CBM) according to established inclusion and exclusion criteria. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. Meta-analysis was conducted to compare the survival rate and postoperative infection rate of primary and secondary implantation.

RESULTS

Seven studies were involved in our research, involving 186 patients. Five of the studies detailed implant success in 106 patients (primary implantation 50, secondary implantation 56), and four studies documented infection after implantation in 117 patients (primary implantation 52, secondary implantation 65); the survival rate of the primary implantation was 93.3%, and the incidence of postoperative infection was 17.3%. The survival rate of the secondary implantation was 93.4%, and 23.1% had postoperative infection. Meta-analysis showed that there was no significant difference in the survival rate between primary implantation and secondary implantation, OR = 0.813 (95% CI 0.383-1.725, P = 0.589 > 0.05), and there was no significant difference in the incidence of postoperative infection, OR = 0.614 (95% CI 0.239-1.581, P = 0.312 > 0.05).

CONCLUSIONS

Based on the results of this study, the research found no significant difference in the survival rate or infection rates between primary and secondary implantation. After appropriate indications selection, primary implantation can be used to reconstruct the dentition with less waiting time, reduce the impact of radiotherapy, and bring a higher quality of life for patients.

Feasibility analysis of bone density evaluation with Hounsfield unit value after fibula flap reconstruction of jaw defect

BACKGROUND

Implant-supported dentures have become an essential means of restoring occlusal function after jaw reconstruction. Bone mineral density (BMD) may influence the success rate of implant denture restorations. This study aimed to explore whether the Hounsfield unit (HU) value can be used to monitor the changing trend of fibular BMD after jaw reconstruction.

RESULTS

A total of 54 patients who underwent maxillar/mandibular reconstruction with a fibula flap were included in this study. There was a significant correlation between the HU value and BMD at 1 week, 3 months, and 6 months after surgery, and both were significantly correlated with follow-up time. The difference between each pair of absorption rates (DAR) was less than 10% in 66.7% and 75.9% of patients at 3 and 6 months; however, the DAR was more than 20% in 12% and 13.8% of patients at 3 and 6 months, respectively.

CONCLUSIONS

There is a significant correlation between HU value and BMD. The HU value can be used to roughly reflect the fibular BMD changing trend in a group of patients as opposed to an individual, and the HU value is not equivalent to BMD.

TRIAL REGISTRATION

ChiCTR, ChiCTR2300069661, retrospectively registered on 22 March 2023. Retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=188953 .

MRONJ of the Mandible—From Decortication to a Complex Jaw Reconstruction Using a CAD/CAM-Guided Bilateral Scapula Flap

Medication-related osteonecrosis of the jaw (MRONJ) has been an integral part of the maxillofacial patient population for some time. The therapeutic concept ranges from conservative approaches over less extended decortications to major jaw resections, which can result in a considerable loss of quality of life. Based on three case reports, this paper presents the long-term history of patients with MRONJ of the mandible, whose disease ultimately resulted in partial or total mandibular resection and subsequent multisegmental reconstruction using a microvascular anastomosed bone flap. Furthermore, a suitable alternative for complex mandibular reconstruction is demonstrated when using a free fibula flap is not possible. The options are limited, particularly when multisegmental restoration of mandibular continuity is required. One case presents a mandible reconstruction using a CAD/CAM-guided bilateral scapular free flap (CAD/CAM = Computer-Aided Design and Manufacturing), which has not been described for this purpose before. Due to the complexity, computer-assisted surgery and patient-specific implants seem reasonable, which is why a special focus was applied to this topic.

Retrospective three-dimensional analysis of bone resorption volumes of free microvascular scapular and fibular grafts

Defects in head and neck regions are standardly treated with microvascular grafts, such as free scapular (SFF) and fibular flaps (FFF), which are subject to a certain amount of bone resorption over time. The aim of this study was the 3-dimensional evaluation of bone resorption volume in both grafts. Over a period of 10 years, computed tomograms (CT) of patients with mandibular reconstructions with SFFs and FFFs were examined. The respective grafts were segmented as well as 3-dimensionally measured. Furthermore, factors such as gender, age, nicotine abuse, previous disease with type 2 diabetes, and adjuvant therapies, were examined for their influence. A total of 211 CT scans from 67 patients (40 SFFs and 27 FFFs) were included in the study. SFFs showed slightly higher median bone volumes (87.60% at 730 days and 86.55% at 1500 days) than FFFs (84.40% at 730 days and 82.10% at 1500 days). When final volumes were considered, FFFs had higher mean volume values (88.22%) than SFFs (83.82%), with significant correlation between resorption volume and time progression (r = 0.357, p = 0.024). All previously mentioned factors had no significant effect on bone resorption. Bone volumes of FFFs showed postoperative volume reductions similar to those of SFFs, with isolated SFFs having markedly lower volume values. The choice of a microvascular graft for reconstruction in the mandible proves difficult regarding bone resorption. The presented results may support decisions about future transplantations.

[Postoperative position change of fibular bone after reconstruction of maxillary defect using free fibular flap]

OBJECTIVE

To investigate the position change of the fibular bone after maxillary reconstruction by free fibular flap and to analyze the factors affecting the position change.

METHODS

Patients who underwent maxillary reconstruction by free fibular flap in the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology from November 2012 to November 2016 were enrolled in this study. CT scans 1 week and 1 year postoperatively were collected and stored in DICOM format. The ProPlan CMF software was used to reconstruct the CT scans and separate the maxilla and each segment of the fibular flap. The Geomagic Control software was used to measure the long axis direction vector of each fibular segment. And the position change direction was recorded. The patients were divided into groups according to the use of the fibula or titanium plate to reconstruct the zygomaticmaxillary buttress.

RESULTS

A total of 32 patients were enrolled. Among them, 21 were in the titanium plate group and 11 in the fibula bone group. The angle between the long axis of the fibular segment and the X axis in the X-Y plane was 95.65°±53.49° and 95.53°±52.77°, 1 week and 1 year postoperatively, and there was no statistical difference (P>0.05). The angle between the long axis of the fibular segment and the X axis in the X-Z plane was 96.88°±69.76° and 95.33°±67.42°, respectively, with statistical difference (P=0.0497). The angular changes of the long axis of the fibular segment in the titanium plate group and the fibular bone group were 3.23°±3.93° and 1.94°±1.78°, respectively, and the angular changes in the X-Z plane were 6.02°±9.89° and 3.27°±2.31°, respectively. There was no significant difference between the groups (P>0.05). The long axis changes of the fibular segment in the X-Y plane for reconstruction of the anterior alveolar, posterior alveolar, and buttress were 3.13°±3.78°, 2.56°±3.17°, and 5.51°±4.39°, respectively. There was a statistical difference (P = 0.023) between the posterior and buttress. In the X-Z plane, theses were 4.94°±4.75°, 5.26°±10.25°, 6.69°±6.52°, respectively. There was no statistical difference among the three groups (P>0.05). The main positional deviation directions of the titanium plate group and the fibular bone group were interior and superior sides, and there was no statistical difference between the two groups (P>0.05).

CONCLUSION

One year postoperatively, the position of the free fibular flap was changed compared with 1 week postoperatively. The position of the free fibular flap was mainly changed to the interior and superior sides.

Retrospective analysis of complications in 190 mandibular resections and simultaneous reconstructions with free fibula flap, iliac crest flap or reconstruction plate: a comparative single centre study

Objectives

The purpose of this study was to evaluate the incidence of complications following mandibular reconstruction and to analyse possible contributing factors.

Materials and methods

Clinical data and computed tomography scans of all patients who needed a mandibular reconstruction with a reconstruction plate, free fibula flap (FFF) or iliac crest (DCIA) flap between August 2010 and August 2015 were retrospectively analysed.

Results

One hundred and ninety patients were enrolled, encompassing 77 reconstructions with reconstruction plate, 89 reconstructions with FFF and 24 reconstructions with DCIA flaps. Cutaneous perforation was most frequently detected in the plate subgroup within the early interval and overall (each p = 0.004). Low body mass index (BMI) and total radiation dosage were the most relevant risk factors for the development of analysed complications.

Conclusions

Microvascular bone flaps have overall less skin perforation than reconstruction plates. BMI and expected total radiation dosage have to be respected in choice of reconstructive technique.

Clinical relevance

A treatment algorithm for mandibular reconstructions on the basis of our results is presented.

Electronic supplementary material

The online version of this article (10.1007/s00784-020-03607-8) contains supplementary material, which is available to authorized users.

Mandibular reconstruction using single piece zygomatic implant in conjunction with a reinforcing Fibular Graft Union: A case report

Presenting to our knowledge, for the first time in literature, a case report on the long term follow-up of an implant retained fixed prosthesis on free fibular reconstruction with a single piece zygomatic implant and single piece bicortical implant via a flapless approach and immediate functional rehabilitation. The technique involved the concept of "Remote Bone Anchorage" in conjunction with the union of grafted free fibula flap with the native mandible. It was facilitated with a single piece zygomatic implant engaged in the mandible and splinted with single piece implants on the grafted fibula as needed for prosthetic functional reconstruction. The author has reported a unique concept of immediate functional rehabilitation in the fibular graft therefore providing additional splinting of the vascularized free fibula to the mandible by splinting them with single piece zygomatic cortical implant.

Cortical bone resorption of fibular bone after maxillary reconstruction with a vascularized fibula free flap: a computed tomography imaging study

This study was performed to evaluate the cortical bone resorption of fibular bone after maxillary reconstruction with a fibula free flap. A total of 35 patients with maxillary defects that were repaired using a fibula flap (62 fibula segments) between January 2011 and January 2016 were enrolled. Computed tomography (CT) images taken 1 week and 1 year postoperative were used to evaluate cortical bone resorption. The 62 fibula segments were measured on four different surfaces in the CT images. At 1 week, the thickness of the cortical bone was 2.57 ± 0.58 mm, 2.72 ± 0.46 mm, 3.84 ± 0.98 mm, and 4.36 ± 0.90 mm for the exterior, interior, superior, and inferior sides, respectively. At approximately 1 year, the cortical bone thickness was significantly reduced to 2.00 ± 0.65 mm (P <  0.01), 2.25 ± 0.60 mm (P <  0.01), 3.37 ± 0.90 mm (P <  0.01), and 2.96 ± 0.84 mm (P <  0.01) for the exterior, interior, superior, and inferior sides, respectively. The cortical bone thickness of fibular bone is significantly reduced 1 year after the restoration of maxillary defects with a fibula free flap, most significantly on the inferior side.

Osseous Changes Over Time in Free Fibular Flap Reconstruction

OBJECTIVES/HYPOTHESIS

Evaluate bone resorption in free fibular grafts and document resorption behavior as compared to dentulous and edentulous autochthonous mandibular bone.

STUDY DESIGN

Retrospective Chart review.

METHODS

Postoperative computed tomography images were used to evaluate fibular graft resorption rates and corresponding sites of the dentulous or edentulous mandible. Bone height, width, and cortical thickness were measured.

RESULTS

Eighteen patients underwent fibula free flap reconstruction following resection of a primary head and neck cancer. Mandibular defects were classified using Jewer's classification. The average interval loss of osseous height was 0.23 ± 0.09 mm/yr for fibula flap, 0.55 ± 0.13 mm/yr for dentulous native mandible, and 0.98 ± 0.41 mm/yr in edentulous native mandible. Change in osseous width was 0.19 ± 0.08 mm/yr, 0.55 ± 0.33 mm/yr, and 0.73 ± 0.15 mm/yr, respectively. Rate of superior cortical resorption was 0.33 ± 0.34 mm/yr, 0.35 ± 0.13 mm/yr, and 0.53 ± 0.11 mm/yr in fibula flap, dentulous, and edentulous mandible, respectively. Inferior cortical resorption rates were quantified as 0.30 ± 0.11 mm/yr, 0.35 ± 0.08 mm/yr, and 0.51 ± 0.08 mm/yr.

CONCLUSIONS

Fibula free flap reconstruction of the mandible provides excellent functional results and allows for stable outcomes. Bone resorption is significantly lower in fibular graft compared with both edentulous and dentulous mandible. Edentulous bone displays significantly increased rates of atrophy in comparison to the dentulous mandible. This may have implications with regard to long-term viability of both the fibular flap and native mandible. The role of dental restoration on overall osseous stability warrants further research.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1113-1116, 2019.

Evaluation of bone resorption in fibula and deep circumflex iliac artery flaps following dental implantation: A three-year follow-up study

Long-term results of dental implant treatment in fibula free and deep circumflex iliac artery (DCIA) free flaps are scarce. The purpose of this study was to assess and compare peri-implant bone resorption of vascularized bone flaps treated with dental implants. A total of 28 patients, 14 fibula and 14 DCIA flaps, respectively, underwent reconstruction of the lower and upper jaw by the use of vascularized bone flaps and were treated with dental implants. Peri-implant bone resorption was measured using digital panographs up to 3 years. Radiographic pictures were taken immediately after implant surgery before prosthetic rehabilitation (T0), the second after 6-12 months (T1), the third after 13-24 months (T2), and the fourth after 25-36 months (T3). Over a period of 3 years, implant resorption changed significantly over time (p_D1 = 0.0113, p_D2 = 0.0232, p_D3 = 0.0143). However, a significant difference in overall resorption between implants with fibula flaps and DCIA could not be detected for the patient average or within the implant-level analysis. Flaps presented minimal resorption from beneath (mean resorption DCIA 0.65, fibula = 0.26). Strong peri-implant bone resorption changed significantly over time. However, no significant difference was observed between fibula and DCIA flaps.

Facial bone reconstruction with prefabricated vascularized calvarium flaps in children and young adults: Advantages and long-term results

INTRODUCTION

Reconstruction of facial bone defects in children is challenging. The use of well-vascularized bone is mandatory to obtain stable lasting results. This study reports our experience of facial bone reconstruction using prefabricated vascularized calvarium flaps.

METHODS

Retrospective case series of 50 patients who underwent 52 maxillary, malar, and mandibular reconstructions between 1988 and 2014 using prefabricated vascularized calvarium flaps. Forty-nine patients suffered from noma sequels; one patient had craniofacial cleft Tessier 3-11. Surgery consisted of a two-step procedure beginning with flap delay and prelamination with skin grafting on the galea. Flap harvest followed at least 2 weeks later (range, 2-16 weeks), including a full-thickness calvarium fragment, which was set into the facial defect.

RESULTS

Early complications concerned wound healing and infections requiring surgical revision in six patients at the recipient and six at the donor site. There was one flap loss. Clinical long-term assessment at 15-year median follow-up (range, 1-27 years) showed good results, assuring facial height and contour. Radiological long-term results demonstrated excellent integration of the flap to the adjacent facial skeleton of the growing child.

CONCLUSIONS

Prefabricated vascularized calvarium flaps are an effective, safe and lasting method for reconstruction of facial bone defects in children.

Free flap reconstruction for patients with bisphosphonate related osteonecrosis of the jaws after mandibulectomy

INTRODUCTION

Bisphosphonate related osteonecrosis of the jaws (BRONJ) is a recognised unwanted effect of these drugs which affect bone remodelling. Treatment options range from conservative approaches through local bone debridement to free flap reconstruction following segmental resection. This current study aims to evaluate clinical outcomes after microvascular tissue transfer in BRONJ patients.

MATERIAL AND METHODS

A total of 212 BRONJ patients were included in this prospective investigation. Those who met defined inclusion criteria and received a surgical intervention were reviewed regularly during a follow-up period of at least 6 months.

RESULTS

Twenty-five patients (11.8%) received free flap reconstructions. A mean of 2.12 local debridements were performed before microvascular tissue transfer. A mean of 29.25% showed BRONJ recurrence after minimalist surgical intervention, compared to significantly less in patients after resection and free flap reconstruction. The postoperative fistula rate was significantly higher in patients, who received mucoperiosteal flaps.

DISCUSSION

This study underlines the importance and effectiveness radical resection and free flap reconstruction in the complex and challenging surgical treatment of BRONJ patients in a large patient cohort study. Nevertheless, all patients received radical intervention after failure of minimally invasive treatment. An individualized analysis and planning is necessary to identify appropriate patients for free flap reconstructions.

Evaluation of computer-assisted mandibular reconstruction with vascularized iliac crest bone graft compared to conventional surgery: a randomized prospective clinical trial

BACKGROUND

Computer-assisted surgery plays an increasingly important role in mandibular reconstruction, ensuring the best possible masticatory function and aesthetic outcome.

METHODS

Twenty patients were randomly assigned to computer-assisted or conventional mandibular reconstruction with vascularized iliac crest bone graft in a prospective study design.Virtual surgical planning was based on preoperative CT-data using specific surgical planning software. A rapid prototyping guide transferred the virtual surgery plan to the operation site. During surgery the transplant ischemic time, reconstruction time, time for shaping the transplant and amount of bone removed were measured. Additionally, the difference in the intercondylar distance before and after surgery was calculated.

RESULTS

Computer-assisted surgery shortened the time of transplant ischemia (P < 0.005) and defect reconstruction (P < 0.001) compared to conventional surgery. The time to saw and shape the transplant at the donor site was shorter using conventional surgery (P < 0.005); therefore, the overall time for surgery didn't change (P = 0.527). In the computer-assisted group, the amount of bone harvested equaled the defect size, whereas the transplant size in the conventional group exceeded the defect site by 16.8 ± 5.6 mm (P < 0.001) on average. The intercondylar distance before compared to after surgery was less affected in the computer-assisted than in the conventional group (P < 0.001).

CONCLUSIONS

The presented study shows that computer-assisted surgery can help reduce the time for mandibular defect reconstruction and consequently the transplant ischemic time. In the computer-assisted group, the iliac crest donor site defect was downsized and the postoperative condyle position was less altered, reducing possible risks of postoperative complications and donor site morbidity.

TRIAL REGISTRATION

DRKS00005181.

Comparison of outcome of microvascular bony head and neck reconstructions using the fibular free flap and the iliac crest flap

Several microvascular free flaps are available for reconstruction of the osseous components after resections for head and neck cancer. We have prospectively evaluated patients treated by bony microsurgical reconstruction to identify predictors of adverse outcomes for delayed wound healing and failure of free flaps. All patients from July 2007 to June 2011 who had reconstructions with microvascular fibular or iliac crest flaps immediately after resection of the tumour were evaluated. There were a total of 156 bony free flaps: 120 (77%) fibular and 36 (23%) iliac crest flaps. A total of 133 (85%) were successful. Delayed wound healing was more common with the iliac crest flap (p=0.01) at the intraoral site (p=0.04). Significantly more iliac crest free flaps failed (p=0.02). Anastomosis to the facial artery (p=0.05) and facial vein (p=0.04), and duration of overall operating time were associated with a significantly higher risk of failure of the flap. Patients with cancer of the head and neck who require microsurgical bony reconstruction are at increased risk of postoperative complications. Significantly more complications were found with the iliac crest flap, whereas the fibular flap was associated with a significantly longer operating time.

Reconstructive oral and maxillofacial surgery

BACKGROUND

The incidence of malignancies in the head and neck region is rising. Head and neck tumors are the eighth most frequent type of malignancy in German men, forming 3.3% of the total. As a result, the demand for functionally successful and esthetically pleasing reconstructions has increased.

METHODS

Review based on a selective analysis of the pertinent literature and the guidelines of the German Association of Oral and Maxillofacial Surgery as well as the authors' clinical and scientific experience.

RESULTS

Microsurgical flap transfer has become the most important type of reconstruction, with a more than 90% rate of success, i.e., complete integration of the transplant in the recipient site. The most frequent complications are thromboses of the vein or artery of the pedicle. For each specific defect constellation, the most appropriate donor sites have been identified. Some donor sites are used for more than one defect. The principal risk factors for flap loss are prior operations on the neck, atherosclerosis, and previous radiation treatment. New developments include the use of perforator flaps, which can be anastomosed to very small vessels in the face, and wrist-carriers, which offer complete independence from head and neck vessels.

CONCLUSION

The treatment, rehabilitation, and follow-up care of patients with tumors of the head and neck must be carried out by an interdisciplinary team. Full awareness of the available options for reconstruction helps the radiation therapist, oncologist, psychooncologist, general practitioner, and dentist to coordinate their efforts and advise their often mutilated and sometimes suicidal patients effectively.

Quality of life evaluation for patients receiving vascularized versus nonvascularized bone graft reconstruction of segmental mandibular defects

PURPOSE

Head and neck neoplasms requiring surgical resection of the mandible can have negative consequences on patient quality of life. For patients with segmental resections, the vascularized fibular free flap and nonvascularized iliac crest are frequently used. The fibula has surpassed the iliac crest in popularity due to the success associated with a vascularized graft; however, there still remain significant advantages with the nonvascularized graft. There has not been a study comparing the quality of life associated with these two methods of mandibular reconstruction. We carried out the following study to compare quality of life of both grafts in an attempt to help guide therapeutic decisions.

PATIENTS AND METHODS

Twenty-nine patients at the University of California, San Francisco undergoing mandibular resection with subsequent reconstruction with either a vascularized fibular free flap or nonvascularized iliac crest bone graft were identified. Patient quality of life was assessed with a modified version of the University of Washington Quality of Life Questionnaire, version 4.

RESULTS

Eighteen patients responded (10 reconstructed previously with a fibula, 8 with iliac crest reconstructions). Patients with an iliac crest bone graft had significantly better chewing and swallowing scores (P = .04, P = .049 respectively). There was also a trend for better taste (P = .067). When patients with a history of radiation therapy were excluded, differences in chewing and swallowing were not significant (P = .26 and P = .31 respectively), whereas taste was (P = .038).

CONCLUSIONS

These findings suggest that reconstruction with the iliac crest had benefits in improved function (chewing, swallowing, and taste) rather than esthetics, donor site morbidity, or psychologic discomfort as was anticipated. However, prior radiation, a relatively frequent therapy in this patient population, presents an important confounding factor. Radiation therapy is difficult to control for without limiting an already scarce patient pool, and bears with it significant morbidity that likely influenced these findings. Further study is warranted to confirm the results and further distinguish the 2 groups.